CLINICAL HANDBOOK OF SCHIZOPHRENIA

218 IV. PSYCHOSOCIAL TREATMENTcommitment over a considerable time period, and there have been large variations in theintensity of the interventions.The content and format of family interventions have also been modified to addressthe differing needs of particular families.First-Episode PsychosisRelatives of individuals experiencing their first episode of psychosis report a higher riskof distress compared to family members of individuals who have a more chronic courseof illness. Family members have numerous concerns at this time and are likely to have lessknowledge and understanding of psychosis on which to draw. This may be an opportunetime to engage family members, because they are likely to be searching for support andinformation (Addington & Burnett, 2004). Families need to be offered support to managecrises and an initial explanatory model of psychosis that they can use to understandtheir experiences. This can then be built on gradually, along with other aspects of familyinterventions, including problem-solving skills, communication training, cognitive reappraisal,and working with relapse prevention plans.Substance Use and PsychosisIt is widely recognized that many people with psychosis misuse street drugs or alcohol,and that this “dual diagnosis” is associated with many complex problems for families.Specialist approaches to working with these difficulties have been described by Barrowclough(2003), who described an intervention that sought to promote a family responseto match the patient’s stage of change regarding substance use. This family interventionwas conducted alongside individual work with the patient to address substance use. Thisrandomized controlled trial combining family and individual treatment demonstratedgood outcomes for patients.Group Family WorkWorking with groups of families who share similar problems has a number of advantages:Participants can be encouraged to share experiences and coping strategies that haveworked for them. Many variations on the group format have been used; some have includedpatients, and others have been largely restricted to relatives, so that they can talkopenly without fear of upsetting the patient. Evaluation studies of multiple-family interventionformats have shown inconsistent results, and in a meta-analysis, Pilling and colleagues(2002) found that, compared to single-family treatments, group treatments had apoorer outcome.RESULTS FROM THE STUDIES AND DISCUSSIONOF EVIDENCE BASE FOR FAMILY INTERVENTIONSA number of meta-analytic reviews (Mari & Streiner, 1994; Pharoah, Mari, & Streiner,1999; Pilling et al., 2002; Pitschel-Walz, Leucht, Bauml, Kissling, & Engel, 2001) of thefamily intervention have been published, including studies in which patients had a diagnosisof schizophrenia or schizoaffective disorder; in which there was some form of controlor comparison group against which to evaluate any benefits from the experimentaltreatment; and in which patient relapse or hospitalization was examined as the main out-